Metabolic syndrome and benign prostatic hyperplasia: association or coincidence?
© Rył et al. 2015
Received: 13 July 2015
Accepted: 14 October 2015
Published: 29 October 2015
It has been suggested that individuals with metabolic syndrome (MetS) may be prone to developing benign prostatic hyperplasia (BPH), but the direction of causality remains uncertain. The objective of this cross-sectional study was to evaluate the association between BPH and MetS in men who were referred to surgery for BPH. We were interested in identifying the anthropometric, metabolic, and hormonal factors that potentially influence the risk of both conditions.
The study was conducted on 128 males with BPH and 141 without BPH (the control group). Fasting glucose, insulin, lipid profiles, total and free testosterone, estradiol, sex-hormone binding protein (SHBG), dehydroepiandrosterone sulfate (DHEA-S), homeostasis model assessment (HOMA-IR) index, and lipid accumulation product (LAP) were all evaluated.
The prevalence of MetS was higher in patients with BPH than in the controls (58 vs. 41 %; P = 0.007). In comparison to the controls, patients with BPH had higher levels of cholesterol, low density lipoproteins, DHEA-S, insulin, and HOMA-IR, but lower levels of high-density lipoproteins (HDL), estradiol, and SHBG. The significant predictors of BPH were MetS (OR = 1.961), age (OR = 0.11), HDL (OR = 0.91), insulin (OR = 1.224), SHBG (OR = 0.98), and estradiol (OR = 0.978). Waist circumference and LAP inversely correlated with total and free testosterone and SHBG.
Our study confirmed the frequent coexistence of MetS and BPH. This association seems to be a consequence of the MetS-related metabolic derangements, changes in the sex-hormone milieu, and lowered SHBG levels.
KeywordsBenign prostatic hyperplasia Metabolic syndrome Hormones
Benign prostatic hyperplasia (BPH) is the most common urological condition among elderly males, affecting approximately half of men over 80 years of age. It usually begins as a simple micronodular hyperplasia with a subsequent macroscopic nodular enlargement that may result in bladder outlet obstruction and the development of lower urinary tract symptoms (LUTS) . Although many inflammatory, hormonal, lifestyle, and environmental factors that may predispose to BPH have been identified, the molecular and stromal mechanisms involved in the pathogenesis of this condition have not yet been fully elucidated. It has been suggested that certain sex-hormone environments—including lower androgen levels and higher estrogen levels—may contribute to the development of BPH [2, 3], as estrogens promote the androgen effects, leading to increase in prostate weight . On the other hand, other studies have shown an opposite, positive association between testosterone level and the severity of LUTS,  or no relationship between circulating sex hormones and urological symptoms . Much less is known about the association between BPH and the level of sex-hormone binding globulin (SHBG); to date, studies have yielded inconsistent results. Although some studies have failed to find an association between SHBG levels and the incidence of BPH or the severity of LUTS [7, 8], other reports have demonstrated that SHBG is inversely associated with larger prostate glands [9, 10].
More recently, it has been suggested that individuals with metabolic syndrome (MetS) or its individual components—including central obesity, hyperinsulinemia, insulin resistance, and dyslipidemia—also may be prone to developing BPH and LUTS [3, 11, 12]. On the other hand, some earlier studies found no such relationship [13, 14].
The objectives of the current study were (1) to evaluate the association between BPH and MetS, as defined by the International Diabetes Federation (IDF) diagnostic criteria, and (2) to identify anthropometric, metabolic, and hormonal factors that potentially influence the risk of both conditions.
The study group consisted of males aged 50–75 years who had been referred to the university-affiliated Department of Urology in Szczecin due to moderate-to-severe LUTS, including filling, irritative, voiding, and obstructive symptoms. Using the standard International Prostate Symptom Score (IPSS) tool, a quality of life questionnaire, and prostate imaging, patients were diagnosed; those receiving a diagnosis of BPH were referred to transurethral resection of the prostate (TURP), according to current recommendations and practical guidelines . Eligibility criteria were, according to the European Association of Urology , included in prostate volume above 20–80 ml on transrectal ultrasonography and IPSS result 8 or more.
The control group consisted of age-matched men who had IPSS scores between 0 and 7 and who were neither diagnosed nor considered for treatment for BPH. These subjects were randomly selected from the local general practitioner registers. The exclusion criteria in both groups included a body mass index above 35.0 kg/m2, malignancy in the past 5 years, heart failure, severe liver diseases, and chronic kidney disease. Overall, there were 128 males with BPH and 141 without BPH who completed all the study procedures. Informed consent was obtained from each patient in the study. The study protocol was approved by the Ethics Committee of the Pomeranian Medical University in Szczecin and conformed to the ethical guidelines of the 1975 Declaration of Helsinki (6th revision, 2008).
For all study participants, the weight, height, waist circumference (WC), and sitting blood pressure were measured. The body mass index (BMI) was then calculated from the weight and height. Using automated methods and commercially available assays, we measured fasting glucose, insulin, lipid profile (including triglycerides, total cholesterol and high (HDL) and low-density (LDL) lipoproteins), luteinizing hormone (LH), total testosterone (reference ranges in men 8–11, 8 nmol/l) and free testosterone, estradiol, SHBG, and dehydroepiandrosterone sulfate (DHEA-S). Insulin resistance was evaluated by the homeostasis model assessment (HOMA-IR) index, calculated as blood glucose (mmol/l−1) × insulin concentration (µIU/ml−1)/22.5 . We used the HOMA-IR cut-off of 2.77 to identify subjects with insulin resistance [15, 18]. The lipid accumulation product (LAP) was calculated using the following equation: LAP = (waist circumference in centimeters − 65) × triglycerides (nmol/l). LAP, an estimate of lipid accumulation in adults, has been shown to be a marker of metabolic risk and is a useful tool for stratifying the risk of unfavorable obesity-related outcomes [19, 20].
MetS was defined using the IDF criteria as the presence of central obesity (WC ≥ 94 cm) and any two of the following components: (1) HDL < 1.03 mmol/l or specific treatment for this lipid abnormality; (2) systolic blood pressure ≥ 130, diastolic blood pressure ≥ 85 mm Hg, or treatment of previously diagnosed hypertension; (3) fasting plasma glucose ≥ 5.55 mmol/l or previously diagnosed type-2 diabetes; and (4) triglyceride level ≥ 1.71 mmol/l or specific treatment for this lipid abnormality .
The descriptive statistics included frequency distributions (number with condition and percentage) for categorical variables and means, standard deviation (SD), and range for continuous variables. Differences among groups were evaluated by an independent t-test or nonparametric Mann–Whitney U-test for continuous variables, and by Chi-square test with Yates’ correction for dichotomous variables. Univariate and multiple regression analyses were used to evaluate the independent predictors of MetS and BPH. The relationship between pairs of quantitative variables was represented using Spearman’s rank correlation coefficient. Data were considered to be significant at P < 0.05.
Baseline characteristics of study participants
BPH (n = 128)
Controls (n = 141)
Body mass index (kg/m2)
Total testosterone (nmol/l)
Free testosterone (pmol/l)
BPH (n = 128)
Controls (n = 141)
Waist > 94 cm
BMI > 25.0 kg/m2
Blood glucose > 5.55 mmol/la
HDL < 1.03 mmol/la
Triglycerides > 1.71 mmol/la
Blood pressure > 130/85 mm Hga
The subjects with BPH had higher DHEA-S and LH but lower estradiol and SHBG. In both groups, there were high prevalences of overweight or obesity (BMI above 25.0 kg/m2) and of abdominal obesity (waist circumference > 94 cm). The overall prevalence of overweight in all the males participating in the study was 72 %; the value was similar for abdominal obesity. Importantly, despite the similar frequency in both groups of each of the individual components of MetS, the prevalence of MetS was significantly higher in patients with BPH (58 vs. 41 %; p = 0.007).
Anthropometric, metabolic and hormonal characteristics of subjects with and without metabolic syndrome (patients with BPH)
Metabolic syndrome (n = 74)
Without metabolic syndrome (n = 54)
Body mass index (kg/m2)
Total testosterone (nmol/l)
Free testosterone (pmol/l)
Prediction of prevalent BPH by age and metabolic and hormonal factors
95 % CI
Body mass index (kg/m2)
Total testosterone (nmol/l)
Free testosterone (pmol/l)
Correlations between anthropometric measurements, LAP, lipid profiles and sex hormones in patients with BPH and MetS
Total testosterone (nmol/l)
Free testosterone (pmol/l)
Total cholesterol (mmol/l)
In this cross-sectional study, we found a high prevalence of MetS and its individual components among patients with BPH who were referred for TURP. In these cases, we found that age and levels of HDL cholesterol, fasting insulin, SHBG, LH, DHEA-S, and estradiol were significantly associated with BPH. Additionally, MetS was a robust single predictor of BPH. The latter finding is consistent with many previous reports suggesting that an association between BPH and MetS may be plausible [11, 12, 22–25], although it is not yet fully understood.
Recently, Vignozzi et al.  proposed an interesting three-hit hypothesis on the development of BPH, which may also be helpful in understating the mutual relationship between BPH and MetS. According to this hypothesis, an overt or subclinical inflammation (first hit) could be autosustained or overlapped by metabolic alternations (second hit) and changes in sex-hormone levels (third hit). The combined effects of these may result in overexpression of toll-like receptors, transformation of prostatic cells into antigen-presenting cells, and up-regulation of growth factors (andromedins), leading to prostate enlargement. Among hormonal determinants of BPH, the majority of studies have reported sex steroid imbalances between total or free testosterone, dihydrotestosterone, estrogen, and progesterone levels [2–7], although their circulating levels did not necessarily reflect the causal relationship with prostatic volume and severity of LUTS.
However, meta-analysis  of epidemiological evidences between MetS and LUTS secondary to benign prostatic hyperplasia did not demonstrate significant differences of IPSS, IPSS-voiding and IPSS-storage by men with or without MetS. Presence of MetS was not significantly associated with moderate-to-severe LUTS (odds ratio = 1.13; P = 0.53) and only altered serum triglycerides and diabetes were associated with this risk.
In addition to these sex-steroid derangements, our results suggest that they may be also extended by changes in circulating DHEA-S and SHBG. Only a few studies in the literature have evaluated SHBG in patients with BPH, and the results have been inconsistent [7–10]. In our series, SHBG concentration was negatively associated with the prevalence of BPH. Moreover, in comparison to the controls, in cases with BPH there were significantly higher levels of DHEA-S and lower levels of SHBG. However, the clinical usefulness of SHBG as a marker of BPH risk seems uncertain, because its serum concentration, like testosterone, is greatly influenced by aging and coexisting obesity . Aside from BPH, it also has been postulated that low SHBG concentrations might be the primary determinant of the incidence of MetS . Indeed, a similar conclusion is suggested by our study. We observed lower SHBG levels in subjects with BPH and coexisting MetS than in those without MetS; however, SHBG negatively correlated with BMI, LAP, and waist circumference, suggesting that its low concentration may be influenced by increased body size, unfavorable fat distribution, and lipid accumulation. This, in turn, may support the third hit in the concept of metabolic alternations in the pathogenesis of BPH . Accordingly, numerous observational data indicate a close link between central obesity and an increased risk of BPH. Giovannucci et al.  studied more than 25,000 men and determined that men with WC > 109 cm were 100 % more likely to present LUTS and 38 % more likely to require surgery for BPH, as compared to those with waist circumferences < 109 cm. Likewise, data from the National Health and Nutrition Examination Survey III (NHANES III) showed an association between waist circumference and LUTS, suggesting that progressive prostate enlargement in obese men could induce the occurrence of urinary symptoms .
Waist circumference, a major component of MetS, is a surrogate measure of visceral adipose tissue, the accumulation of which is associated with a cluster of metabolic abnormalities, including impaired glucose tolerance, insulin resistance, hypertension, and unfavorable lipid profiles, all of which are risk factors for type-2 diabetes and cardiovascular disease. LAP, calculated from WC and serum triglyceride levels, possesses similar diagnostic and predictive value [19, 20, 31]. Unexpectedly in this study, neither BMI nor waist circumference were determinants of the prevalence of BPH; however, among the studied men with and without BPH, we found a high proportion of men who were obese or centrally obese (72 %), which is likely to have had an impact on our results.
Among other metabolic alternations in males with BPH, we observed higher levels of total and LDL cholesterol, lower HDL cholesterol, and the higher prevalence of increased triglycerides above 1.71 mmol/l than in those without BPH. Moreover, these subjects also had significantly higher insulin levels and HOMA-IR values. From previous studies, it can be determined that MetS—and in particular abnormal lipid profiles including hypertriglyceridemia, low HDL cholesterol, and up-regulation of LDL cholesterol—could induce or maintain an inflammatory state within the prostate [26, 32, 33]. This process could be exacerbated by changes in sex-hormone levels (as observed in our study), such as relative hyperestrogenism, decreases in SHBG levels, and androgen deficiency—that is, medical conditions commonly associated with MetS, and in particular with abdominal obesity. In addition, subjects with excess visceral fat are often prone to developing insulin resistance which, in turn, may be an independent risk factor for BPH [34–36]. Hence, obese, dyslipidemic, and aged males are at risk for MetS, whose components are important determinants of prostate enlargement [7, 11] as well as of other abdominal obesity-related comorbidities, including cardiovascular disease, obstructive sleep apnea, and nonalcoholic fatty liver disease .
Our study had some limitations. First, due its observational nature, the associations observed between MetS and BPH may not be causal, on account of some unknown confounding or reverse causality. Second, there was an overexpression in our sample of overweight or obese subjects, which likely overestimated the true prevalence of MetS. Therefore, our results may not apply to the general population of men aged over 50—in particular to normal weight and underweight individuals. Finally, we did not collect data on diet, smoking, or alcohol consumption—i.e., on the modifiable independent factors that can significantly influence the risks of MetS and BPH.
In conclusion, our study confirmed the frequent coexistence of MetS and BPH. This association seems to be a consequence of the MetS-related changes in the sex-hormone milieu and metabolic derangements. Therefore, as obesity, diet (excess consumption of alcohol, red meat, and fat), and a sedentary lifestyle strongly predispose to the development of BPH [4, 38], the broad promotion of a healthy lifestyle and of healthy dietary patterns may be an important tool in both the prevention and treatment of this condition.
AR, IR and ML conceived and designed the study. AR, IR, MS, BD and AL conducted the study. AR and TM analyzed the data. TM wrote the manuscript. All authors read and approved the final manuscript.
We thank the participants in this study as well as the nursing and medical staff for their help. This study was financially supported by project MB-322-124/14, Pomeranian Medical University in Szczecin.
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Briganti A, Capitanio U, Suardi N, Gallina A, Salonia A, Bianchi M, et al. Benign prostatic hyperplasia and its aetiologies. Eur Urol Suppl. 2009;8:865–71.View ArticleGoogle Scholar
- Rohrmann S, Nelson WG, Rifai N, Kanarek N, Basaria S, Tsilidis KK, et al. Serum sex steroid hormones and lower urinary tract symptoms in Third National Health and Nutrition Examination Survey (NHANES III). Urology. 2007;69:708–13.View ArticlePubMedGoogle Scholar
- De Nunzio C, Aronson W, Freedland SJ, Giovannucci E, Parsons JK. The correlation between metabolic syndrome and prostatic diseases. Eur Urol. 2012;61:560–70.View ArticlePubMedGoogle Scholar
- Coffey DS. Similarities of prostate and breast cancer: evolution, diet, and estrogens. Urology. 2001;57:31–8.View ArticlePubMedGoogle Scholar
- Favilla V, Cimino S, Castelli T, Madonia M, Barbagallo I, Morgia G. Relationship between lower urinary tract symptoms and serum levels of sex hormones in men with symptomatic benign prostatic hyperplasia. BJU Int. 2010;106:1700–3.View ArticlePubMedGoogle Scholar
- Litman HJ, Bhasin S, O’Leary MP, Link CL, McKinlay JB, BACH Survey Investigators. An investigation of the relationship between sex-steroid levels and urological symptoms: results from the Boston Area Community Health survey. BJU Int. 2007;100:321–6.View ArticlePubMedGoogle Scholar
- Antunes AA, Araújo LH, Nakano E, Muracca E, Srougi M. Obesity may influence the relationship between sex hormones and lower urinary tract symptoms. Int Braz J Urol. 2014;40:240–6.View ArticlePubMedGoogle Scholar
- Zeng QS, Xu CL, Liu ZY, Wang HQ, Yang B, Xu WD, et al. Relationship between sex hormones levels and degree of benign hyperplasia in Chinese aging men. Asian J Androl. 2012;14:773–7.PubMed CentralView ArticlePubMedGoogle Scholar
- Haghsheno MA, Mellström D, Behre CJ, Damber JE, Johansson H, Karlsson M, et al. Low 25-OH vitamin D is associated with benign prostatic hyperplasia. J Urol. 2013;190:608–14.View ArticlePubMedGoogle Scholar
- Joseph MA, Wei JT, Harlow SD, Cooney KA, Dunn RL, Jaffe CA, et al. Relationship of serum sex-steroid hormones and prostate volume in African American men. Prostate. 2002;53:322–9.View ArticlePubMedGoogle Scholar
- Gacci M, Corona G, Vignozzi L, Salvi M, Serni S, De Nunzio C, et al. Metabolic syndrome and benign prostatic enlargement: a systematic review and meta-analysis. BJU Int. 2015;115:24–31.View ArticlePubMedGoogle Scholar
- De Nunzio C, Cindolo L, Gacci M, Pellegrini F, Carini M, Lombardo R, et al. Metabolic syndrome and lower urinary tract symptoms in patients with benign prostatic enlargement: a possible link to storage symptoms. Urology. 2014;8:1181–7.View ArticleGoogle Scholar
- Temml C, Obermayr R, Marszalek M, Rauchenwald M, Madersbacher S, Ponholzer A. Are lower urinary tract symptoms influenced by metabolic syndrome? Urology. 2009;73:544–8.View ArticlePubMedGoogle Scholar
- Park HK, Lee HW, Lee KS, Byun SS, Jeong SJ, Hong SK, et al. Relationship between lower urinary tract symptoms and metabolic syndrome in a community based elderly population. Urology. 2008;72:556–60.View ArticlePubMedGoogle Scholar
- Gravas S, Bachmann A, Descazeaud A, Drake M, Gratzke C, Madersbacher S, et al. Guidelines on the management of non-neurogenic male lower urinary tract symptoms (LUTS), incl. benign prostatic obstruction (BPO). Eur Assoc Urol 2014. Available from: uroweb.org/wp-content/uploads/Non-Neurogenic-Male-LUTS_2705.pdf.Google Scholar
- Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ. EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol. 2004;2004(46):547–54.View ArticleGoogle Scholar
- Summer AE, Cowie CC. Ethnic differences in the ability of triglyceride levels to identify insulin resistance. Atherosclerosis. 2008;196:696–703.View ArticleGoogle Scholar
- Miccoli R, Biamchi C, Odoguardi L. Prevalence of the metabolic syndrome among Italian adults according to ATPII definition. Nutr Metab Cardiovasc Dis. 2005;15:250–4.View ArticlePubMedGoogle Scholar
- Ioachimescu AG, Brennan DM, Hoar BM, Hoogwerf BJ. The lipid accumulation product and all-cause mortality in patients at high cardiovascular risk: a PreCIS database study. Obesity (Silver Spring). 2010;18:1836–44.View ArticleGoogle Scholar
- Maturana MA, Moreira RM, Spritzer PM. Lipid accumulation product (LAP) is related to androgenicity and cardiovascular risk factors in postmenopausal women. Maturitas. 2011;70:395–9. doi:10.1016/j.maturitas.2011.09.012.View ArticlePubMedGoogle Scholar
- Alberti KG, Zimmet P, Shaw J, IDF Epidemiology Task Force Consensus Group. The metabolic syndrome: a new world-wide definition. Lancet. 2005;366:1059–62.View ArticlePubMedGoogle Scholar
- Zhang X, Zeng X, Liu Y, Dong L, Zhao X, Qu X. Impact of metabolic syndrome on benign prostatic hyperplasia in elderly Chinese men. Urol Int. 2014;93:214–9.View ArticlePubMedGoogle Scholar
- Pashootan P, Ploussard G, Cocaul A, De Gouvello A, Desgrandchamps F. Association between metabolic syndrome and severity of lower urinary tract symptoms: observational study in a 4666 European men cohort. BJU Int. 2015. doi:10.1111/bju.12931. Accessed 17 September 2014.
- Fleshner NE, Bhindi B. Metabolic syndrome and diabetes for the urologist. Can Urol Assoc J. 2014;8(7–8 Suppl 5):S 159–61.Google Scholar
- Ozden C, Ozdal OL, Urgancioglu G, Koyuncu H, Gokkaya S, Memis A. The correlation between metabolic syndrome and prostatic growth in patients with benign prostatic hyperplasia. Eur Urol. 2007;51:199–206.View ArticlePubMedGoogle Scholar
- Vignozzi L, Rastrelli G, Corona G, Gacci M, Forti G, Maggi M. Benign prostatic hyperplasia: a new metabolic disease? J Endocrinol Invest. 2014;37:313–22.View ArticlePubMedGoogle Scholar
- Russo GI, Castelli T, Urzì D, Privitera S, Fragalà E, La Vignera S, et al. Connections between lower urinary tract symptoms related to benign prostatic enlargement and metabolic syndrome with its components: a systematic review and meta-analysis. Aging Male. 2015;14:1–10.View ArticleGoogle Scholar
- Brand JS, van der Tweel I, Grobbee DE, Emmelot-Vonk MH, van der Schouw YT. Testosterone, sex hormone-binding globulin and the metabolic syndrome: a systematic review and meta-analysis of observational studies. Int J Epidemiol. 2011;40:189–207.View ArticlePubMedGoogle Scholar
- Bhasin S, Jasjua GK, Pencina M, D’Agostino R Sr, Coviello AD, Vasan RS, et al. Sex hormone–binding globulin, but not testosterone, is associated prospectively and independently with incident metabolic syndrome in men: the Framingham heart study. Diabetes Care. 2011;34:2464–70.PubMed CentralView ArticlePubMedGoogle Scholar
- Giovannucci E, Rimm EB, Liu Y, Leitzmann M, Wu K, Stampfer MJ, et al. Body mass index and risk of prostate cancer in US health professionals. J Natl Cancer Inst. 2003;95:1240–4.View ArticlePubMedGoogle Scholar
- Bozorgmanesh M, Hadaegh F, Azizi F. Predictive performances of lipid accumulation product vs. adiposity measures for cardiovascular diseases and all-cause mortality, 8.6-year follow-up: tehran lipid and glucose study. Lipids Health Dis. 2010;9:100.PubMed CentralView ArticlePubMedGoogle Scholar
- Lotti F, Corona G, Vignozzi L, Rossi M, Maseroli E, Cipriani S, et al. Metabolic syndrome and prostate abnormalities in male subjects of infertile couples. Asian J Androl. 2014;16:295–304.PubMed CentralView ArticlePubMedGoogle Scholar
- Gacci M, Vignozzi L, Sebastianelli A, Salvi M, Giannessi C, De Nunzio C, et al. Metabolic syndrome and lower urinary tract symptoms: the role of inflammation. Prostate Cancer Prostatic Dis. 2013;16:101–6.View ArticlePubMedGoogle Scholar
- Qu X, Huang Z, Meng X, Zhang X, Dong L, Zhao X. Prostate volume correlates with diabetes in elderly benign prostatic hyperplasia patients. Int Urol Nephrol. 2014;45:499–504.View ArticleGoogle Scholar
- Hammarsten J, Damber JE, Karlsson M, Knutson T, Ljunggren O, Ohlsson C, et al. Insulin and free oestradiol are independent risk factors for benign prostatic hyperplasia. Prostate Cancer Prostatic Dis. 2009;12:160–5.View ArticlePubMedGoogle Scholar
- Vikram A, Jena GB, Ramarao P. Increased cell proliferation and contractility of prostate in insulin resistant rats: linking hyperinsulinemia with benign prostate hyperplasia. Prostate. 2010;70:79–89.View ArticlePubMedGoogle Scholar
- Russo GI, Cimino S, Fragalà E, Privitera S, La Vignera S, Condorelli R, et al. Relationship between non-alcoholic fatty liver disease and benign prostatic hyperplasia/lower urinary tract symptoms: new insights from an Italian cross-sectional study. World J Urol. 2015;33:743–51.View ArticlePubMedGoogle Scholar
- Raheem OA, Parsons JK. Associations of obesity, physical activity and diet with benign prostatic hyperplasia and lower urinary tract symptoms. Curr Opin Urol. 2014;24:10–4.View ArticlePubMedGoogle Scholar